ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION & PHARMACY USER GUIDE

Transcription

1 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION & PHARMACY USER GUIDE 2005 Office of the Medical Director Rev 1/05

2 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES TABLE OF CONTENTS Directory General pg. 2 Pharmacy System Tips pg. 4 Clinics pg. 6 Psychiatrists pg. 10 Pharmacy Network pg. 12 Prescription pg. 14 Medication Formulary System Formulary pg. 20 Clozapine Monitoring Committee pg. 26 Atypical Antipsychotic Requirements pg. 37 Abnormal Involuntary Movement Scale pg. 40 Positive and Negative Syndrome Scale pg. 42 Psychoactive Medication Dosing Ranges Childhood and Adolescent pg. 44 Adult pg. 47 Drug Distribution Policy and Procedures pg. 51 2

3 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Telephone Directory Office of the Medical Director (510) Richard P. Singer, M.D... (510) Medical Director FAX (510) Douglas Del Paggio, Pharm.D., M.P.A... (510) Director of Pharmacy Services FAX (510) Alice Myong, Pharm.D (510) Clinical Pharmacist FAX (510) Pharmaceutical Care Network (PCN) Help Desk Line (800) PA Fax Line. (916) Eligibility Fax Line. (916) Medi-Cal Stockton Direct Number (209) Medi-Cal TAR Fax (Stockton).. (800) Poison Control (800) BHCS Share of Cost Assistance (510) BHCS MediCal Issue Date Assistance.. (510)

4 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES PHARMACY SYSTEM TIPS TOPIC REFILLS LOST/STOLEN MEDICATION VACATION or TRAVEL SUPPLY of MEDICATION NON-FORMULARY PSYCHOTROPIC MEDICATION NON-FORMULARY NON-PSYCHOTROPIC MEDICATION DENIED TARs AMOUNT PRESCRIBED DIFFERENT THAN AMOUNT APPROVED BY MEDI-CAL on TAR PRESCRIPTION NOT PICKED UP BY CLIENT MEDI-CAL SHARE OF COST PROCEDURES A client can return for a refill when 75% of a day supply or 82% of a day supply is used. The client s physician must call the pharmacy, or indicate on the prescription backside that the patient s medications were lost or stolen. The client s physician must call the pharmacy, or indicate on the prescription backside that the client s supply of medications is for vacation/travel. One additional refill is the maximum amount that can be concurrently dispensed. The client s physician must document on the prescription backside two trials of formulary medication in the same therapeutic class listed in the formulary. Otherwise, the patient must be registered with the Office of the Medical (510) for prior approval. The patient must be registered with the Office of the Medical (510) , for prior approval A copy of the denied TAR and prescription must be faxed by the pharmacist to PCN at (916) or (916) The prescription will then be covered by BHCS. The pharmacist will submit a One Time Only TAR requesting the different amount, with an explanation provided by the patient s psychiatrist. Call the client s prescribing physician, or team members associated with the client. If a share of cost exists, it is requested that the pharmacist call BHCS Finance at (510) prior to prescription adjudication to check if all patient clinical services have been entered chronologically. 4

5 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES CLINICS 5

6 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Community Support Centers 1. Alameda CSC 1429 Oak St., Alameda, CA Asian Community Mental th Street, Ste 201, Oakland, CA Health Services 3. BACS nd St., Ste 650, Oakland, CA Bonita House 6333 Telegraph Ave., Ste 102, Oakland, CA BOSS North 1820 Jefferson St., Oakland, CA BOSS South Meekland Ave., Hayward, CA La Clinica de la Raza, 1501 Fruitvale Ave., Oakland, CA Casa del Sol 8. CHANGES 7200 Bancroft Ave., Ste133, Oakland, CA CONREP 2060 Fairmont Dr., San Leandro, CA Crisis Response Services 568 West Grand Ave., Oakland, CA North 11. Crisis Response Services Foothill Blvd., San Leandro, CA South 12. Criminal Justice MH 2060 Fairmont Dr., San Leandro, CA Dublin High School 8151 Village Parkway, Dublin, CA Eden CSC 2045 Fairmont Dr., San Leandro, CA La Familia Counseling Mocine Ave., Hayward, CA Services 16. Guidance Clinic 2200 Fairmont Drive, San Leandro, CA Oakland CSC MacArthur Blvd., Oakland, CA Sausal Creek Outpt th Avenue, Oakland, CA Stabilization Service 19. STARS Community 545 Estudillo Ave., San Leandro, CA Service Program 20. Tri-City CSC Liberty St., Ste G710, Fremont, CA Valley CSC 3730 Hopyard Road, Pleasanton, CA West Oakland Health 2730 Adeline St., Oakland, CA Council Mental Health 23. Woodroe Place Woodroe Ave., Hayward, CA FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX FAX (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (925) (925) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (510) (925) (925) (510) (510) (510) (510)

7 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Community Support Centers BHCS Administration 2000 Embarcadero Cove Oakland, CA (510) Marye L. Thomas, M.D., Director Richard P. Singer, M.D., Medical Director Douglas Del Paggio, Pharm.D., MPA., Director of Pharmacy Services Alameda Mental Health 1429 Oak St. Alameda, CA (510) Said Shefayee, M.D. Alan Cohen, M.D. Asian Community Mental Health Services th Street, Suite 201 Oakland, CA (510) Tuong Vi Ta, M.D. John Fong, M.D. Tim Lukaszewski, M.D. Karen Yun, M.D. Bay Area Community Services nd Street, Suite 650 Oakland, CA (510) Neal Edwards, M.D. BOSS North 1820 Jefferson Street Oakland, CA ) Neal Edwards, M.D. BOSS South Meekland Avenue Hayward, CA (510) Neal Edwards, M.D. 7 Bonita House 6333 Telegraph Avenue, Suite 102 Oakland, CA (510) Floyd Brown, M.D. CHANGES 7200 Bancroft Avenue, Suite 133 Oakland, CA (510) Edward Lim, M.D. Margaret E. Frank, M.D. Conditional Release Program (CONREP) 2060 Fairmont Drive San Leandro, CA (510) Mcheko Graves-Matthews, M.D. Criminal Justice Mental Health 2060 Fairmont Drive San Leandro, CA (510) Fred Rosenthal, M.D. Said Shefayee, M.D. Mcheko Graves-Matthews, M.D. Anthony Coppola, M.D. Barbara Vignola, M.D. John Dupre, M.D. Karen Gudiksen, M.D. Kermit Johnson, M.D. Crisis Response Services North 568 West Grand Avenue Oakland, CA (510) Luisito Roxas, M.D. Stephen Hague, M.D. Crisis Response Services South Foothill Blvd San Leandro, CA (510) Stephen Hague, M.D. Kermit Johnson, M.D.

8 Dublin High School 8151 Village Parkway Dublin, CA (925) Sudha Manjunath, M.D. Eden Community Support Center 2045 Fairmont Drive San Leandro, CA (510) Roger Mendelson, M.D. Jerome Berney, M.D. (Child) Luisito Roxas, M.D. Alan Cohen, M.D. Peter Lavalle, M.D. La Clinica de la Raza Casa Del Sol 1501 Fruitvale Avenue Oakland, CA (510) David Flanagan, M.D. Tim Lukaszewski, M.D. Thomas Meyer, M.D. La Familia Counseling Service Mocine Hayward, CA (510) Daniel Kusnir, M.D. David Flanagan, M.D. Adrian Grant, M.D. Oakland Community Support Center MacArthur Boulevard Oakland, CA (510) James Hinson, M.D. Angela Callendar, M.D. (Child) Paul Opsvig, M.D. (Child) Giridhar Reddy, M.D. Bernard Sklar, M.D. STARS Community Services Program 545 Estudillo Avenue San Leandro, CA (510) John Cotrufo, D.O. Tri-City Community Support Center Liberty St., Ste. G710 Fremont, CA (510) John Cotrufo, D.O. Seema Sehgal, M.D. Sui Kwong Sung, M.D. Sudha Manjunath, M.D. (Child) Sausal Creek Outpatient Stabilization Svc th Avenue Oakland, CA (510) Rick Jenkins, M.D. Stuart Gluck, M.D. Margaret E. Frank, M.D. Valley Community Support Center 3730 Hopyard Pleasanton, CA (925) Stanley Jung, M.D. Catherine Felisky, M.D. (Child) Harinder Auluck, M.D. Sudha Manjunath, M.D. (Child) West Oakland Mental Health 2730 Adeline Oakland, CA (510) Neal Edwards, M.D. Clyde Martin, M.D. Woodroe Place Woodroe Avenue Hayward, CA (510) Neal Edwards, M.D. John George Pavilion 2060 Fairmont Drive San Leandro, CA (510) Kurt Biehl, M.D. 8

9 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES PSYCHIATRISTS 9

10 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES PSYCHIATRISTS SERVICE SITE MAIN PHONE # VOICE MAIL Auluck, Harinder M.D. Guidance Clinic (510) (510) auluck@bhcs.mail.co.alameda.ca.us Valley Community Support (925) Berney, Jerome, M.D. Eden Children s (510) (510) berney@bhcs.mail.co.alameda.ca.us Brown, Floyd, M.D. Bonita House (510) (510) floyd@bonitahouse.org ext. 27 Callendar, Angela, M.D. Oakland Children s Center (510) (510) callendar@bhcs.mail.co.alameda.ca.us Cohen, Alan, M.D. Eden Adult (510) (510) cohen@bhcs.mail.co.alameda.ca.us Alameda Community Support (510) Coppola, Anthony, M.D. Criminal Justice (925) (925) coppola@bhcs.mail.co.alameda.ca.us Cotrufo, John, D.O. Tri-City Adult (510) (510) cotrufo@bhcs.mail.co.alameda.ca.us STARS (510) *Dupre, John, M.D. Criminal Justice (925) (925) dupre@bhcs.mail.co.alameda.ca.us Edwards, Neal, MD. BACS (510) (510) Woodroe Place West Oakland BOSS No & So (510) (510) (510) (510) Felisky, Catherine, M.D. Valley Children s (925) felisky@bhcs.mail.co.alameda.ca.us Flanagan, David, M.D. La Familia (510) dflanagan@laclinica.org La Clinica (510) Fong, John, M.D. Asian Community MH (510) (510) johnswf@acmhs.org Frank, Margaret E., M.D. CHANGES Sausal Creek Outpt Gluck, Stuart, M.D. Sausal Creek Outpt sgluck@telecarecorp.com Stabilization Graves-Matthews, Criminal Justice (925) (925) matthews@bhcs.mail.co.alameda.ca.us Mcheko, M.D. CONREP (510) Grant, Adrian, M.D. La Familia (510) *Gudiksen, Karen, M.D. Criminal Justice (925) (925) gudiksen@bhcs.mail.co.alameda.ca.us Hague, Stephen, M.D. Crisis Services South (510) (510) hague@bhcs.mail.co.alameda.ca.us Crisis Services North (510) (510) Hinson, James, M.D. Oakland Adult (510) (510) hinson@bhcs.mail.co.alameda.ca.us Jenkins, Rick, M.D. Sausal Creek Outpatient (510) Stabilization Johnson, Kermit, M.D. Crisis Services North/South (510) (510) johnson_k@bhcs.mail.co.alameda.ca.us Jung, Stanley, M.D. Valley Community Support (925) (925) jung@bhcs.mail.co.alameda.ca.us Kusnir, Daniel, M.D. La Familia (510) ext. 12 (T/R) (510) (M/W/F) (510) pager kusnirdan@sbcglobal.net Lavalle, Peter, M.D. Eden Adult (510) (510) Lavalle@bhcs.mail.co.alameda.ca.us Lim, Edward, M.D. CHANGES (510) Lukaszewski, Tim, M.D. Asian Community MH La Clinica (510) (510) (510) timl@acmhs.org drtim@laclinica.org Manjunath, Sudha, M.D. Tri-City Children s (510) (510) manjunath@bhcs.mail.co.alameda.ca.us Valley Children s (925) Martin, Clyde, M.D. West Oakland (510) Mendelson, Roger, M.D. Eden Adult (510) (510) mendelson@bhcs.mail.co.alameda.ca.us Meyer, Thomas, M.D. La Clinica (510) tmeyer@laclinica.org Opsvig, Paul, M.D. Oakland Children s (510) (510) opsvig@bhcs.mail.co.alameda.ca.us Reddy, Giridhar, M.D. Oakland Adult (510) reddy@bhcs.mail.co.alameda.ca.us Rosenthal, Fred, M.D. Criminal Justice (510) (925) rosenthal@bhcs.mail.co.alameda.ca.us Roxas, Luisito, M.D. Eden Adult (510) (510) roxas@bhcs.mail.co.alameda.ca.us Crisis Services North (510) (510) Sehgal, Seema, M.D. Tri-City Adult (510) (510) sehgal@bhcs.mail.co.alameda.ca.us Shefayee, Said, M.D. Criminal Justice Alameda Community Support (925) (510) (925) shefayee@bhcs.mail.co.alameda.ca.us Sklar, Bernard, M.D. Oakland Adult (510) (510) sklar@bhcs.mail.co.alameda.ca.us Sung, Sui Kwong, M.D. Tri-City Adult (510) (510) sung@bhcs.mail.co.alameda.ca.us Ta, Tuong Vi, M.D. Asian Community MH (510) (510) *Vance, Brandon, M.D. CHANGES (510) Vignola, Barbara, M.D. Criminal Justice (925) (925) vignola@bhcs.mail.co.alameda.ca.us Yun, Karen, M.D. Asian Community MH (510) (510) kareny@acmhs.org *Substitutes during absences 10

11 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES PHARMACY NETWORK 11

12 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES PHARMACY NETWORK ALAMEDA Telephone Fax Longs Drug Store # A Island Drive Alameda (510) (510) Longs Drug Store # Marina Village Parkway Alameda (510) (510) Longs Drug Store # Santa Clara Avenue Alameda (510) (510) Webster Pharmacy 1553 Webster Street Alameda (510) (510) BERKELEY Longs Drug Store # San Pablo Avenue Berkeley (510) (510) Longs Drug Store # Shattuck Avenue Berkeley (510) (510) CASTRO VALLEY Longs Drug Store # Castro Valley Boulevard Castro Valley (510) (510) DUBLIN Longs Drug Store # Regional Street Dublin (925) (925) EL CERRITO Longs Drug Store # San Pablo Avenue El Cerrito (510) (510) Longs Drug Store # El Cerrito Plaza El Cerrito (510) (510) EMERYVILLE Longs Drug Store # San Pablo Avenue Emeryville (510) (510) FREMONT Longs Drug Store # Mission Boulevard Fremont (510) (510) Longs Drug Store # Fremont Hub Center Fremont (510) (510) Longs Drug Store # Fremont Blvd Fremont (510) (510) (Brookvale) Longs Drug Store # Driscoll Road Fremont (510) (510) HAYWARD Longs Drug Store # West Jackson Street Hayward (510) (510) Longs Drug Store # Foothill Boulevard Hayward (510) (510) Medicine Chest 925 B Street Hayward (510) (510) LIVERMORE Longs Drug Store # First Street Livermore (925) (925) Longs Drug Store # First Street Livermore (925) (925) NEWARK Longs Drug Store # Newark Boulevard Newark (510) (510) OAKLAND The Apothecary 7200 Bancroft Ave., #268 Oakland (510) (510) Leo s Day & Night 1776 Broadway Oakland (510) (510) New Oakland Pharmacy th Street Oakland (510) (510) New Oakland Pharmacy # th Street Oakland (510) (510) La Clinica de la Raza 3451 E. 12 th Street Oakland (510) (510) Longs Drug Store # Redwood Road Oakland (510) (510) Longs Drug Store # st Street Oakland (510) (510) Longs Drug Store # Fruitvale Avenue Oakland (510) (510) Longs Drug Store # Mountain Boulevard Oakland (510) (510) Longs Drug Store # Webster Street Oakland (510) (510) Longs Drug Store # Broadway Oakland (510) (510) Longs Drug Store # Lakeshore Avenue Oakland (510) (510) Longs Drug Store # th Street Oakland (510) (510) PINOLE Longs Drug Store 1401 Tara Hills Drive Pinole (510) (510) PLEASANTON Longs Drug Store # Rosewood Drive Pleasanton (925) (925) Rite Aid # Hopyard Avenue Pleasanton (925) (925) SAN LEANDRO Longs Drug Store # Lewelling Boulevard San Leandro (510) (510) Longs Drug Store # E. 14 th Street San Leandro (510) (510) Longs Drug Store # E. 14 th Street San Leandro (510) (510) Longs Drug Store # Washington Avenue San Leandro (510) (510) SAN RAMON Longs Drug Store # San Ramon Valley Blvd. San Ramon (925) (925) Longs Drug Store # Market Place San Ramon (925) (925) Longs Drug Store # Alcosta Boulevard San Ramon (925) (925) BOLD = MIA Program Pharmacy 12

13 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES PRESCRIPTION 13

14 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES [ ] Crisis Response Service No (51) [ ] La Familia (61) [ ] Crisis Response Service So (52) [ ] Guidance Clinic (62) [ ] Alameda CSC (53) [ ] Oakland CSC (63) [ ] Asian CSC (54) [ ] STARS (70) [ ] BACS (55) [ ] Tri-City CSC (64) [ ] Bonita House (56) [ ] Valley CSC (65) (925) [ ] La Clinica (57) [ ] West Oakland CSC (66) [ ] CONREP (58) [ ] Woodroe Place (67) [ ] Criminal Justice (59) [ ] John George Psych Pav (68) [ ] Eden CSC (60) [ ] CHANGES (73) [ ] BOSS-North (71) [ ] Dublin High School (74) (925) [ ] BOSS-South (72) [ ] Sausal Creek Outpt (75) PRINT PATIENT S NAME: BIRTHDATE: SSN: CL #: Address 14 PHYSICIAN NAME: Phone LICENSE & DEA #: Patient: [ ] Medi-Cal [ ] Pvt. Insurance [ ] Self Pay Medication: [ ] Medi-Cal (covered) [ ] Non-Medi-Cal covered (over) [ ] No Payer Source [ ] Sensitive Service # [ ] Pt. Enrolled in MIA Program [ ] Non-formulary (over) MEDICATION AND STRENGTH Number of Medications Ordered: AMT.# DIRECTIONS MIA CIRCLE REFILL AMT DRUG CODE PharmD M fg Signature: Date: Patient s Initial BHCS Visit

15 NON-FORMULARY MEDICATION REQUEST/T.A.R. MEDICAL JUSTIFICATION FOR PHARMACIST (Must be completed for non-medi-cal covered medications) 1. Requested medication: 2. Diagnosis description: 3. ICD-9-CM Diagnosis Code (Must match diagnosis description): 4. Medical Justification: Previous Medication Trials Dosage/Frequency Dates Duration Previous Medication Documentation of Adverse Effect/Lack of Efficacy Clinical Update: AIMS PANSS (neg subscale )

16 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY SYSTEM 16

17 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY SYSTEM Overview: A formulary system is a method for the medical staff of BHCS to evaluate, appraise, and select from the numerous available drug entities and drug products that those are considered most useful for care of our patient population. Only those selected drugs will be routinely available for prescribing from the community pharmacies. Components of the formulary system include a method for requesting drug placement onto and withdrawal from the formulary, evaluating the role of new medications released to the market, programs to monitor drug use and adverse events, as well as provision of drug information and education related to optimizing patient care and outcomes. A formulary is not a restrictive list of medications; it is a flexible and dynamic system that reflects the current clinical judgment of the medical staff and BHCS, and needs constant evaluation and revision. Purpose: A formulary system has three purposes and associated benefits for Alameda County Behavioral Health Care Services: 1. The principle purpose is to ensure the quality and appropriateness of medication provision within BHCS. New drug evaluations, dosing guidelines, drug use evaluations, and adverse drug reaction reporting are some of the ways to support this principle. 2. The second purpose is to teach appropriate drug therapy to staff through education. Drug monographs, treatment guidelines, and in-service educational programs all provide staff benefit. 3. Finally, a formulary system provides cost-effective drug therapy, not simply drug cost reductions. With a limited formulary, the pharmacy network can maintain a more efficient control on drug costs, while focusing on the quality of care. Medication Classification: 1. Formulary Medication can be prescribed by authorized BHCS clinicians 2. Application/Approval Necessary Prior to Dispensing -clozapine (Clozaril) Candidates must be approved by Clozapine Monitoring Committee through a prior application process (see Clozapine Monitoring Committee section). As part of this application, both the AIMS and PANSS (including Negative Subscale) are necessary prior to therapy, and quarterly for the initial 6 months of treatment. 17

18 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY SYSTEM 3. AIMS/PANSS Required Prior to Dispensing a) ziprasidone (Geodon) b) aripiprazole (Abilify) Candidate must have both AIMS and PANSS (including Negative Subscale) scores written on the flip side of the Alameda County BHCS Prescription form (see Atypical Antipsychotic section). These scores are necessary prior to the first prescription, and at 6 months of treatment (at initiation, and 180 days). 4. Non-Formulary Psychotropic Medication Medications from one of the following therapeutic categories: a) Antipsychotic Agent b) Antidepressant c) Mood Stabilizer d) Antiparkinsonian/Antidyskinetic Agent e) Antianxiety/Hypnotic f) Psychostimulant are only available if two prior medication trials of formulary agents in the same therapeutic class were unsuccessful. The medications, doses, and outcomes need to be documented on the flip side of the Alameda County BHCS Prescription form. 5. Non-Formulary Non-psychotropic Medication Medications not belonging to one of the above therapeutic categories must be approved by the Office of the BHCS Medical Director ( ) prior to prescribing, or the medication will not be dispensed. Information necessary includes patient name, PSP#, medication name and specific justification. Formulary Revisions: TARs: Medication addition/deletions to the Alameda County BHCS Formulary will be made in writing to the Office of the Medical Director. All proposed changes will be discussed in the Psychiatric Committee (PPC), and an action recommendation made to the Medical Director. The Medical Director will make the final decision. All Medi-Cal eligible patients prescribed non Medi-Cal covered medication must have the flip side of the Alameda County BHCS Prescription form completed. This information is necessary for the network pharmacy to complete a TAR for submission to Medi-Cal. 18

19 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES FORMULARY 19

20 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY ANTIDEPRESSANTS Covered Serotonin Selective Reuptake Inhibitors Ave $ per Day Medi-Cal? Notes citalopram 10, 20, 40 mg, 10 mg/5cc $ 2.20 No Prior Authorization by Medi-Cal escitalopram 10, 20 mg $ 2.50 Yes fluoxetine 10, 20 mg, 40 mg, 20 mg/5 ml $ 0.33 Yes 40 mg Prior authorization by MediCal fluvoxamine 25, 50, 100 mg $ 3.61 Yes paroxetine 10, 20, 30, 40 mg, 10 mg/5 ml $ 2.67 Yes Only brand name covered by MediCal sertraline 25, 50, 100 mg, 20 mg/cc $ 3.00 Yes 20 Covered Miscellaneous Agents Ave $ per Day Medi-Cal? Notes bupropion 75, 100 mg, 100mg SR, 150mg $ 3.00 Yes Only brand name covered by MediCal SR, 200mg SR mirtazapine 15, 30, 45mg, sol tabs $ 2.50 Yes phenelzine 15 mg $ 1.65 No Not covered by Medi-Cal trazodone 50, 100, 150 mg $ 0.30 Yes venlafaxine 25, 37.5, 75, 100, 150 mg XR: 37.5 mg, 75 mg, 150 mg $ 3.95 Yes Only XR covered by Medi-Cal Covered Tricyclic Compounds Sizes Ave $ per Day Medi-Cal? Notes amitriptyline 10, 25, 50 mg, 100 mg $ 0.30 Yes clomipramine 25, 50, 75 mg $ 1.65 Yes desipramine 10, 25, 50, 75, 100, 150 mg $ 2.30 Yes doxepin 10, 25, 50, 75, 100, 150 mg $ 0.50 Yes imipramine 10, 25, 50 mg $ 0.75 Yes nortriptyline 10, 25, 50, 75 mg $ 0.40 Yes protriptyline 5, 10 mg $ 1.60 Yes

21 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY ANTIPSYCHOTICS Covered 2 ND Generation (Atypical Antipsychotics) Ave $ per Day Medi-Cal? Notes olanzapine 2.5, 5, 7.5, 10, 15mg, 20mg, & Zydis $ Yes quetiapine 25, 100, 200, 300 mg $ 5.60 Yes risperidone 0.5, 1, 2, 3, 4 mg, 1 mg/ml soln & M-tabs 0.5, 1, 2 mg $ 4.85 Yes AIMS/PANSS required Prior to Dispensing aripiprazole 5, 10, 15, 20, 30 $ Yes ziprasidone 20, 40, 60, 80 mg $ 7.45 Yes 21 Application/Approval Necessary Prior to Dispensing clozapine 25, 100 mg $ 2.25 Yes 1 st Generation chlorpromazine 10, 25, 50, 100, 200 mg, 10 mg/5 ml, 30 mg/ml, 100 $.05 Yes mg/ml fluphenazine 1, 2.5, 10 mg, 0.5 mg/ml, 5 mg/ml, 2.5 mg/cc (inj) $.30 Yes fluphenazine dec. 25 mg/cc (inj) 25mg inj = $20.00 Yes haloperidol 0.5, 1, 2, 5, 10, 20 mg, 2 mg/ml, 5 mg/cc (inj) $.05 Yes haloperidol dec. 50 mg/cc (inj), 100 mg/cc (inj) 50 mg inj= $28.00 Yes loxapine 5, 10, 25, 50 mg $.50 Yes molindone 5, 10, 25, 50, 100 mg, 20 mg/ml $ 1.35 Yes perphenazine 2, 4, 8, 16 mg, 16 mg/5 ml, 5mg/cc (inj) $.50 Yes pimozide 2 mg $.35 No Not covered by Medi- Cal thioridazine 10, 15, 25, 50, 100, 150, 200 mg, 30 mg/ml, 100 mg/ml $.05 Yes thiothixene 1, 2, 5, 10, 20 mg, 5 mg/ml $.20 Yes trifluoperazine 2, 5, 10 mg $.40 Yes

22 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY MOOD STABILIZERS 22 Covered Ave $ per Day Medi-Cal? Notes carbamazepine 100, 200 mg, 100 mg/5 ml $ 0.54 Yes divalproex 125, 250, 500 mg, 500 mg $ 3.45 Yes lamotrigine 25, 100, 150, 200 mg $ 6.20 Yes lithium carbonate 150 mg, 300 mg $ 0.80 Yes lithium CR 300, 450 mg $ 1.50 No Not covered by Medi-Cal valproic acid 250 mg, 250 mg/5 ml $ 2.10 Yes ANTIPARKINSONIAN/ANTIDYSKINETIC AGENTS Covered Ave $ per Day Medi-Cal? Notes amantadine 100 mg cap, 50 mg/5 ml $.10 Yes atenolol 25, 50, 100 mg $.05 Yes benztropine 0.5, 1, 2 mg, 1 mg/cc (inj) $.05 Yes diphenhydramine 25 mg, 50 mg, 10 mg/ml, 50 mg/cc (inj) $.05 Yes 25 mg not covered by Medi-Cal propranolol 10, 20, 40, 60, 80, 90 mg, 4 mg/ml $.05 Yes 8 mg/ml trihexyphenidyl 2, 5 mg, 2 mg/5 ml $.25 Yes

23 ALAMEDA COUTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY ANTIANXIETY/HYPNOTICS Covered Benzodiazepines Ave $ per Day Medi-Cal? Notes alprazolam 0.25, 0.5, 1, 2 mg $.10 Yes clonazepam 0.5, 1, 2 mg $.60 Yes diazepam 2 20 mg tab $.05 No Not covered by Medi-Cal flurazepam 15, 30 mg $.05 Yes Medi-Cal = Restricted to use in tx of insomnia lorazepam 0.5, 1, 2 mg $.25 Yes Medi-Cal = Max tabs #30, 3 rxs per 75 days temazepam 15, 30 mg $.05 Yes Medi-Cal = Restricted to use in tx of insomnia triazolam 0.125, 0.25 mg $.25 Yes Medi-Cal = Restricted to use in tx of insomnia 23 Non-Benzodiazepines buspirone 5, 10, 30 mg $ 1.40 Yes chloral hydrate 250, 500 mg $.25 Yes zolpidem 5, 10 mg $.85 Yes Medi-Cal = Restricted to use in treatment of insomnia, 3 rxs per 75 days zaleplon 5, 10 mg $.85 Yes Medi-Cal = Restricted to use in treatment of insomnia, 3 rxs per 75 days PSYCHOSTIMULANTS Ave $ per Day Medi-Cal? Notes dextroamphetamine 5, 10 mg, $.20 Yes Medi-Cal = Restricted to Attention Deficit Disorder age 4-16 dextroamphetamine 5, 10, 15 mg $ 1.10 No Not covered by Medi-Cal sustained release methylphenidate 5, 10, 20 mg $.20 Yes Medi-Cal = Restricted to Attention Deficit Disorder age 4-16 methylphenidate CD 20 mg $.65 No Not covered by Medi-Cal (Metadate CD) Ritalin LA 20, 30, 40 mg $.70 No Not covered by Medi-Cal methylphenidate XR (Concerta) 18, 27, 36, 54 mg $ 3.37 No Not covered by MediCal, unless prev. disp. prior to 12/1/2004 & within 100 days of last Rx

24 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY MISC. AGENTS 24 Covered Ave $ per Day Medi-Cal? Notes clonidine 0.1, 0.2, 0.3, 0.5 mg $.05 Yes Patch: 2.5, 5.0, 7.5 mg disulfiram 250, 500 mg $.05 Yes docusate sodium 100, 250 mg $.05 Yes guanfacine 1 mg, 2 mg $.35 Yes hydroxyzine 10, 25, 50 mg $.05 Yes levothyroxin Tabs all strengths $.05 Yes Nicorette Gum 2, 4 mg $.35 No Limited to six months Nicotine Transdermal Patches 7, 14, 21 mg/24 hr. $.70 Yes Limited to six weeks Metamucil powder 390 g $.10 Yes vit E cap all strengths $.05 No Not covered by Medi-Cal multivit/minerals Generic Centrum $.05 No Not covered by Medi-Cal

25 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES CLOZAPINE MONITORING COMMITTEE 25

26 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines I. Background/General Information Clozapine is a dibenzodiazepine derivative indicated for the treatment of psychotic disorders. Numerous studies have demonstrated the effectiveness of this drug for treatment-resistant patients unresponsive to standard antipsychotics, with fewer incidences of troubling extrapyramidal reactions, neuroleptic malignant syndrome, and tardive dyskinesia. However, due to the 1% to 2% incidence of agranulocytosis associated with use of the medication as well as the high cost, special protocols have been developed for prescribing and distributing the drug. A. Clozapine Monitoring Committee No patient will be started on clozapine within the outpatient clinics of Alameda County BHCS without prior approval by the Clozapine Monitoring Committee. When patients are referred to a county outpatient clinic from an inpatient facility, the referring psychiatrist is to complete the Clozapine Monitoring Committee Application Form prior to initiating clozapine. If a patient who is already receiving clozapine is admitted to any Alameda County outpatient clinic, and that patient does not meet the Clozapine Patient Criteria below, the patient will be reviewed by the assigned physician and the Clozapine Monitoring Committee for possible change to another clinically appropriate treatment. II. Clozapine Patient Criteria Patients who meet the following criteria will be considered for clozapine initiation: A. Documented history of one of the following diagnoses: 1. Severe schizophrenia 2. Severe schizo-affective disorder 3. Bipolar disorder unresponsive to treatment with lithium, carbamazepine, and valproic acid (divalproex) B. Be over the age of 16 C. A history of trials with at least two different (atypical) antipsychotics which were titrated to the maximum dose, and were maintained for at least 2 months before discontinuation due to inadequacy of symptom response or adverse effects. DRUG DOSE. risperidone 4-8mg olanzapine 15-20mg quetiapine mg ziprasidone mg aripiprazole 10-15mg 26

27 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines D. None of the following complications or contraindications are present: 1. History of clozapine-induced leukopenia, agranulocytosis or granuloctyopenia 2. Medical condition or drug associated with myeloproliferative disease or immunosuppression 3. Severe medical condition, or other illnesses causing central nervous system depression or concurrent organic state 4. Poor medical compliance and/or poor compliance with lab testing 5. Initial WBC < 3500/mm 3 (or neutrophil < 2000/ mm 3 ) 6. History of hypersensitivity to a clozapine related drug (amoxapine, loxapine) 7. History of significant physical illness in the prior month 8. History of blood disorders E. The following potential concerns and complications have been addressed, if applicable: 1. Presence of concurrent active substance abuse 2. History of seizure disorder, or neurological illness i. Finnish or Jewish background, especially Ashkenazi Jew ii. Laboratory or clinical evident of significant hepatic, renal, or cardiopulmonary disease iii. Unexplained abnormalities in laboratory tests within the preceding four weeks iv. Prostatic enlargement or narrow angle glaucoma v. Need for continued use of heterocyclic or MAOI-type antidepressants vi. Concomitant use of (see Table #1, page 35): a. Bone marrow suppressants b. Antihypertensive agents c. CNS depressants d. Highly protein bound drugs e. Substrates/inhibitors/inducers of CYP 1A2, 2D6, and 3A4 vii. History of orthostatic hypotension F. Clozapine Monitoring Committee Application Form (attachment #1) completion and approval. III. Initiation of Clozapine Treatment The following must be completed if the patient is approved for clozapine administration: 1. Physician must be registered as a provider with the National Registry by calling the National Registry or providing the completed forms to the registry. 2. Physician will explain medication to the patient and have patient sign Informed Consent for Clozapine. 3. Physician calls the National Registry to obtain rechallenge clearance authorization. A patient number is received from the National Registry, and documented in the client Medical Record. Telephone Numbers Clozaril (Novartis) Patient Registry (800) FAX (800) Clozapine (IVAX) Patient Registry (800) FAX (800)

28 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines IV. Clozapine Treatment Requirements: A. The following items must be performed prior to initiation of clozapine: 1. WBC with differential 2. Electrolytes, serum creatinine, total protein and albumin, liver function panel 3. Drug screen 4. Pregnancy test, if possibly pregnant (Pregnancy Category B) 5. An assessment of the patient s physical condition 6. Vital signs (including orthostatic BP, pulse) and weight 7. Geriatric patients or patients with history of cardiovascular disease: o ECG or evaluation by internist 8. Patients with history of seizures, recent head trauma or intracranial disease: o EEG or evaluation by internist 9. Registration with the Clozapine National Registry B. The following items must be obtained during clozapine treatment: 1. Review of weekly WBC count and ANC during the initial 6 months of treatment, biweekly for the next 6 months, and every 4 weeks thereafter, if client meets the criteria outlined below (see Monitoring Requirements for Clozapine). 2. Vital signs taken at each visit (including orthostatic BP and pulse). C. Prescription of Clozapine 1. No PRN use of clozapine shall be prescribed. 2. The medication will be prescribed weekly for the first 6 months of therapy. If the patient meets the requirements for biweekly or every 4 weeks blood draws (see Monitoring Requirements for Clozapine), then clozapine may be prescribed on a biweekly or every 4 weeks basis. V. Monitoring Requirements for Clozapine: A. On an ongoing basis the physician will monitor patient outcomes, medication dosing, and adverse effect development, notifying the Clozapine Monitoring Committee of any critical adverse effects, including: 1. Agranulocytosis Agranuloytosis has been estimated to occur in association with clozapine therapy in ~1-2% of patients. Risk is highest during the first 6 months of clozapine therapy, during which weekly blood count monitoring must be performed. 2. Seizure/myoclonus Dose-related seizures have been associated with the use of clozapine. At doses below 300 mg/day seizure risk is comparable to other antipsychotic drugs (~1-2%). At doses between mg/day seizure risk is increased to 3-4%, while in patients receiving mg/day the risk is 5%. Caution should be used when using clozapine for patients having a history of seizures or other predisposing factors. 3. Myocarditis Analyses of postmarketing safety databases suggest that clozapine is associated with an increased risk of fatal myocarditis, especially during, but not limited to, the first month of therapy. Signs and symptoms of myocarditis may include: unexplained fatigue, dypnea, tachypnea, fever, chest pain, and palpitations, other signs/symptoms of heart failure, tachycardia, ST-T wave abnormalities on EKG, or arrhythmias. In patients 28

29 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines in whom myocarditis is suspected, clozapine treatment should be promptly discontinued, and a re-challenge should not be attempted. 4. Marked hypotension Orthostatic hypotension with or without syncope can occur with clozapine treatment and may represent a continuing risk in some patients. It is more likely to occur during initial titration in association with rapid dose escalation and may even occur on first dose. Rarely, collapse can be profound and be accompanied by respiratory and/or cardiac arrest. 5. Respiratory depression see above section Marked hypotension. Also, some of the cases of collapse/respiratory arrest/cardiac arrest during initial treatment occurred in patients who were being administered benzodiazepines, caution is advised when clozapine is initiated in patients taking a benzodiazepine. 6. Increased glucose, lipids and/or weight hyperglycemia, hyperlipidemia, and weight gain have been reported in patients treated with atypical antipsychotics including clozapine. Patients with established diagnoses of diabetes mellitus, hyperlipidemia, or obesity who are started on clozapine should be monitored regularly for worsening of glucose or lipid control, or for further weight gain. Patients with risk factors for the above disorders who are starting clozapine therapy should undergo fasting blood glucose and lipid testing, along with weight monitoring, at the beginning of treatment and periodically during treatment (see Alameda County BHCS Psychotropic Medication Practice Guidelines). 7. Fever or other possible clozapine-induced side effects During clozapine therapy, patients may experience transient temperature elevations above 100.4F, with the peak incidence within the first 3 weeks of treatment. While this fever is generally benign and self-limiting, it may necessitate discontinuing patients from treatment. On occasion, there may be an associated increase or decrease in WBC count. Patients with fever should be carefully evaluated to rule out the possibility of an underlying infectious process or the development of agranulocytosis. In the presence of high fever, the possibility of Neuroleptic Malignant Syndrome must be considered. B. Patients who are being treated with clozapine must have a baseline white blood cell and differential count before initiation of treatment and a WBC/ANC every week thereafter for the first 6 months. If acceptable WBC counts (WBC>3500/mm 3 with ANC>2000/mm 3 ) have been maintained during the first 6 months of continuous therapy, WBC/ANC can be monitored every other week for the next 6 months. Thereafter, if acceptable WBC/ANC (WBC>3500/mm 3 with ANC>2000/mm 3 ) have been maintained during the second 6 months of continuous therapy, WBC/ANC may be monitored every 4 weeks. WBC counts must be monitored weekly for at least 4 weeks after the discontinuation of clozapine. C. Patients with interrupted therapy (flowchart #1, page 34): 1. Patients on clozapine < 6 months with no abnormal blood work and a break in therapy <1 month: continue the weekly blood work from where client has left off for the duration of the six months using the initial start date, before transitioning to biweekly draws. 2. Patients on clozapine < 6 months with no abnormal blood work and a break in therapy >1 month: restart the weekly blood draws for another 6 months, before transitioning to biweekly draws. 29

30 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines 3. Patients on clozapine for 6-12 months with no abnormal blood work and a break in therapy <1 month: restart weekly blood draws for 6 weeks, then continue with biweekly blood draws for another 6 months, before transitioning to every 4 weeks draws. 4. Patients on clozapine for 6-12 months with no abnormal blood work and a break in therapy >1 month: restart weekly blood draws for 6 months, then continue with biweekly blood draws for another 6 months, before transitioning to every 4 weeks draws. 5. Patients on clozapine for > 12 months with no abnormal blood work and a break in therapy <1 month: restart weekly blood draws for 6 weeks, then return to every 4 weeks blood draws. 6. Patients on clozapine for > 12 months with no abnormal blood work and a break in therapy >1 month: restart weekly blood draws for 6 months, then continue with biweekly blood draws for 6 months, before transitioning to every 4 weeks draws. D. Abnormal blood draws (also see Blood Monitoring Requirements Section VI): 1. Regardless of length of clozapine treatment, if a patient experiences an abnormal blood count (WBC <3500/mmj3 or ANC <2000/mm3), but remains rechallengeable (WBC >2000/mm3 and/or ANC >1000/mm3), the following must occur: a. Daily blood draws until WBC >3000/mm3 and ANC >1500/mm3 b. Twice-weekly blood draws until WBC >3500/mm3 and ANC >2000/mm3. c. May rechallenge when WBC >3500/mm3 and ANC >2000/mm3. d. If rechallenged, perform weekly blood draws for 1 year, then biweekly for 6 months, then every 4 weeks thereafter. e. Note: data suggest that patients who have an initial episode of moderate leucopenia (3000/mm3 > WBC=2000/mm3) have up to a 12-fold increased risk of having a subsequent episode of agranulocytosis (ANC 500/mm3) when rechallenged, compared to the full cohort of patients treated with clozapine. Although clozapine may be resumed once a patient is deemed to be rechallengeable, prescribers are strongly advised to reconsider the risks vs benefits of continuing clozapine therapy. E. Obtain an EKG if cardiovascular sequelae are observed. F. Obtaining a clozapine blood level may be warranted if (a) noncompliance is suspected or if (b) there is an unexpected outcome (either inadequate efficacy or clinical evidence of toxicity) resulting from a normally therapeutic dose. There are currently no established guidelines which identify a specific target range of blood levels for clozapine. However, therapeutic response to clozapine has been associated with blood levels of ng/ml. Clinical evidence of toxicity has generally been associated with blood levels of ~800 ng/ml or higher. VI. Blood Monitoring Requirements (see Table 2, page 35): A. Within the week prior to each prescription, a WBC/ANC will be obtained, with results forwarded to the pharmacy working with the individual client. The pharmacy will submit these results to the National Registry. 30

31 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines B. Clozapine should not be initiated if WBC count is <3500/mm3. When the WBC is greater than 3500/mm3, the WBC will be done weekly, biweekly, or every 4 weeks, based upon history of clozapine therapy (see Monitoring Requirements for Clozapine). C. If the total WBC count is above 3500/mm3 but there has been a single drop or a cumulative drop within 3 weeks of over 3000/mm3, perform a repeat WBC/ANC. If repeat values are 3000/mm3=WBC 3500/mm3 and ANC >2000/mm3, then monitor twice weekly. Clozapine treatment may continue but with twice a week WBC & differentials until WBC >3500/mm3 and ANC >2000/mm3. Then return to previous monitoring frequency. D. If the WBC count is between /mm3, or the ANC is between 1000 and 1500/mm3, interrupt clozapine therapy and begin daily WBC counts until WBC >3000/mm3 and ANC >1500/mm3 (see Table 2). E. If the WBC is <2000 or the ANC <1000, discontinue clozapine therapy and do not attempt a rechallenge. F. With a drop in WBC/ANC, the patient may or may not show clinical signs and symptoms such as lethargy, weakness, fever, or sore throat. Monitor closely. VII. Discontinuation of Clozapine: A. Generally clozapine will be tapered and discontinued for patients who have not experienced substantial benefit from it after a trial period of no longer than 24 weeks. At least 12 of those 24 weeks should be at a therapeutic dose. Exceptions may occur on a case-by-case basis with the approval of the Clozapine Monitoring Committee. B. The pharmacy will be notified of a patient s discontinuation of clozapine. C. The Clozapine Monitoring Committee will be notified of a patient s discontinuation. D. Patients must receive weekly blood tests for four weeks following the d/c of clozapine E. The case manager will be informed of the clozapine discontinuation and the need for subsequent blood tests in the event that the patient needs assistance. Rev 06/05 31

32 Alameda County Department of Behavioral Health Care Services Mental Health Division CLOZAPINE APPLICATION Client Name: Birthdate: Chart No.: PSP Client No.: Admit Date: Reporting Unit: DATE PHYSICIAN FACILITY Patient DOB MR# Insurance: [ ] MediCal [ ] MIA [ ]Other: DSM IV: AXIS I AXIS II AXIS III Comments: CURRENT ANTIPSYCHOTIC MEDICATIONS NAME DOSE DURATION [ ] ARIPIPRAZOLE [ ] CHLORPROMAZINE [ ] CLOZAPINE [ ] FLUPHENAZINE po/im [ ] HALOPERIDOL po/im [ ] LOXAPINE [ ] MOLINDONE [ ] OLANZAPINE [ ] PERPHENAZINE [ ] QUETIAPINE [ ] RISPERIDONE [ ] THIORIDAZINE [ ] THIOTHIXENE [ ] TRIFLUOPERAZINE [ ] ZIPRASIDONE EXTRAPYRAMIDAL SIDE EFFECTS/MOVEMENT DISORDERS PAST ANTIPSYCHOTIC MEDICATIONS NAME DOSE DURATION [ ] ARIPIPRAZOLE [ ] CHLORPROMAZINE [ ] CLOZAPINE [ ] FLUPHENAZINE po/im [ ] HALOPERIDOL po/im [ ] LOXAPINE [ ] MOLINDONE [ ] OLANZAPINE [ ] PERPHENAZINE [ ] QUETIAPINE [ ] RISPERIDONE [ ] THIORIDAZINE [ ] THIOTHIXENE [ ] TRIFLUOPERAZINE [ ] ZIPRASIDONE [ ] OTHER ( ) Akathesia ( ) Tremor ( ) Muscle Rigidity/Stiffness ( ) Dystonia ( ) Tardive Dyskinesia Comments 32 OVER

33 CLINICAL STATUS/LEVEL OF IMPAIRMENT SYMPTOMS SEV MOD MILD NONE SYMPTOMS SEV MOD MILD NONE Emotional withdrawal Bizarre appearance Lack of spontaneity Hostility/aggression Blunted affect Inability to experience pleasure Inability to develop relationships Conflict with caregivers A/V hallucinations Conflicts with family Paranoia Delusions Persistent depression Disorganization Suicidal thoughts/plans Attention difficulties Memory/recall difficulties Hx noncompliance with tx Substance abuse active/hx Hospitalization risk CLOZAPINE MEDICAL QUESTIONS: Recent concurrent conditions: [ ] myeloproliferative disease [ ] immunosuppression [ ] organic illness [ ] hypotension [ ] cardiovascular, renal, [ ] head trauma/seizure [ ] blood disorder [ ] pregnancy hepatic or other systemic disorder disease [ ] none of the above Comments: CURRENT MEDICATION REGIMEN: Name Dose Frequency Name Dose Frequency Please FAX to Office of Medical Director FAX: (510) rev 01/05 33

34 34

35 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Clozapine Monitoring Committee Guidelines Table 1 Drug Interactions (see Section II.E.6.) Class Examples Interaction Bone marrow suppressants Carbamazepine, sulfonamides, Additive risk of myelosuppression propylthiouracil, zidovudine, chemotherapeutic agents Antihypertensive agents Hydrochlorothiazide, atenolol, Additive risk of orthostasis, hypotension metoprolol, verapamil, diltiazem, lisinopril, enalapril, prazosin, terazosin CNS depressants Benzodiazepines, lithium, other very sedating agents Additive risks of sedation, respiratory depression, loss of consciousness Highly protein bound drugs Warfarin, divalproex Na, phenytoin, digoxin Clozapine may displace or be displaced from protein binding sites by these agents. Monitor Substrates/inhibitors/inducers of CYP 1A2, 2D6, and 3A4 Erythromycin, ketoconazole, SSRIs can increase clozapine levels Cigarette smoking, carbamazepine may decrease clozapine levels closely for adverse effects. Potential for drug-drug interactions. Monitor for loss/reduction of drug efficacy or for increased toxicity. 35

36 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES ATYPICAL ANTIPSYCHOTICS MONITORING REQUIREMENTS 36

37 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Atypical Antipsychotics Requirements Ziprasidone (Geodon) & Aripiprazole (Abilify) Alameda County Behavioral Health Care Services requires three patient symptom assessment scores to be completed by the patient s physician, and recorded on the flip side of the Alameda County Behavioral Health Care Services Prescription form in order to process the prescription. The scales are the AIMS (Abnormal Involuntary Movement Scale), and PANSS (Positive and Negative Syndrome Scale), including the separate score for the Negative Subscale. WITHOUT THE PRESENCE OF THESE SCORES ON THE PRESCRIPTION, THE MEDICATION CANNOT BE DISPENSED. These objective assessment scales will provide Behavioral Health Care Services with the data to monitor patient outcomes, medication efficacy, and its impact on system costs. After the initial pretreatment score, these scores need to be repeated at six months, and documented on the prescription backside. Risperidone long-acting depot IM (Consta) Risperdal Consta is non-formulary and NOT covered by Medi-Cal (it is only available through the Medi-Cal TAR process). Due to the potential cost impact (see below), current County budget crisis, and no coverage by Medi-Cal, only patients with an approved Medi-Cal TAR or approved through the Janssen Cares Patient Asst. Program will be eligible to receive Risperdal Consta. An application for that program is available from the Office of the Medical Director or at the Risperdal website. Per Inj Per Month Risperdal Consta 25mg IM $ 278 $ mg IM $ 416 $ mg IM $ 555 $1,110 Pharmacoeconomic Study 1. All patients started on Long-acting IM Risperidone will be entered in the study. This includes both MediCal (through approved TAR) and indigent clients (through approved PAP). 2. The PANSS score (overall and negative subscale) would be required upon initiation and again after 6 months treatment. 3. The use of anticholinergic agents, concurrent atypical antipsychotics and impact on metabolic parameters would additionally be monitored. 4. Compliance with 2 week injection schedule will be tracked, as well as dose titration. 37